Healthcare Provider Details

I. General information

NPI: 1619629243
Provider Name (Legal Business Name): MALLORIE BOSWELL GREENWAY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALLORIE LEANNE BOSWELL

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6602 WATERS AVE BLDG C
SAVANNAH GA
31406-2778
US

IV. Provider business mailing address

427 E 51ST ST
SAVANNAH GA
31405-2352
US

V. Phone/Fax

Practice location:
  • Phone: 912-354-7676
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12265
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: